1. What you should tell your patients about radiation Lisa Lowe MD, FAAP Professor, Univ of MO-Kansas City Pediatric Radiologist, Children’s Mercy Hospitals & Clinics

2. Learning Objectives After this talk, learner should be able to: Explain general radiation risk to patients and parents State ways to lower radiation exposure in children Be able to list helpful resources to determine the best radiology test

3. Outline History and Background Radiation Risk Increased use of CT Image Gently Helpful resources What can you say? What can we do?

4. History: Roentgen discovers the X-ray! Dec 1895 – Publication 1 week later - radiograph of wife’s hand

5. History: Radiology - fastest translational research Mid 1896, in practice, including fluoroscopy < 9 months from publication

6. History: X rays became a public spectacle Patented shoe fitting fluoroscope –Bloomingdales FASCINATION!

7. History: Side effects appeared later Vision impaired Skin injury Hair loss

8. History: Risk of radiation “exposed” 1956 Alice Stewart, MD, reports X-Ray risks to fetuses –Argued no radiation was safe –Radiation effects grossly underestimated 1945 US drops atomic bomb –Life Span Study cohort of atomic bomb survivors –> 50 years –Hiroshima Nagasaki –Increased risk of solid cancers –Children highest cancer mortality rates

9. Radiation risk: Biological effects of radiation Damage to DNA Damage to DNA is rapid Damage to DNA may lead to genomic instability Induction of cancer takes many years

10. Children are more radiosensitive Longer lifetime to manifest radiation-induced injury (cancer, cataracts) Children 2-10x more sensitive than adults Radiation Risks in Children: No Debate

11. Increased use X-rays: Invention of CT 1979 Nobel Prize in Physics Allan Cormack Godfrey Hounsfield

12. Increased use: Helical CT Significant increase in the use of CT from 2001 to 2006 –Increase of 10% per year 62 million CTs done per year –6-11% of all CT’s done in children Initially multidetector and 3D CT increased radiation doses by 3 to 10X 50% of all medical radiation ?? Dose quantification Arch, Michael and Donald P. Frush. “Pediatric Body MDCT: A 5-year follow up survey of scanning parameters used by Pediatric Radiologists.” AJR 2008; 191: 611-617.

13. Increased use of CT: AJR Feb 2001 Increased use of CT: AJR Feb 2001 < 20% cases 1 in 500 - 1,000

14. Brenner et al: AJR 2001 Increased use & radiation risk Each exam (therefore dose) is cumulative

15. Hall. Pediatric Radiology. Apr 2002 Increased use & radiation risk AGE at exposure is most important risk factor Females 2X males –Breast –Thyroid

16. Image Gently Campaign Society for Pediatrics Radiology (SPR) & American Academy of Pediatrics (AAP) plus 33 other medical organizations formed the Alliance for Radiation Safety in Pediatric Imaging - 2008 Represents over 400,000 healthcare professionals promoting appropriate and high quality CT for children

17. Image Gently Campaign ALARA principle –As Low As Reasonably Achievable 4 Image Gently guidelines: –Scan only when necessary –Scan only indicated region –Reduce or “child-size” the radiation dose –Scan once –www.imagegently.comwww.imagegently.com

18. Helpful resources: ACR website Imaging guidelines and appropriateness criteria on the Amer College of Radiology (ACR) website: –http://www.acr.org/s_acr/bin.asp?TrackID= &SID=1&DID=14800&CID=1848&VID=2&DO C=File.PDFhttp://www.acr.org/s_acr/bin.asp?TrackID= &SID=1&DID=14800&CID=1848&VID=2&DO C=File.PDF

19. Helpful resources: AAP website Radiology section of the AAP Imaging guidelines: http://www.aap.or g/sections/radiolo gy/default.cfmRad iation safety information for parents & pediatricians http://www.aap.or g/sections/radiolo gy/default.cfm

20. Radiation report card

21. Helpful resources: CMH Radiology website Children’s Mercy Hospital Radiology website

22. Sample newsletters: Image gently campaign

23. How do we respond? One size does NOT fit all We all must ask? Appropriate to do exam? Appropriate timing of exam? Appropriate modality?

24. Radiologists’ responsibility  Understand radiation doses  Review requests for higher dose studies  Discuss with clinicians and parents/patients PRN  Child size technical factors How Do We Respond?

25. Examples Sinus CT –Old: 150 mAs –New: 30 mAs Scoliosis CT Craniosynostosis CT 5x lower dose! }

26. Pediatricians’ responsibility:  Understand radiation doses of modalities  Know which facilities are “kid friendly!  Don’t ass-u-me?  ASK, even demand!  Order on medical indications not parental/legal pressure  Discuss options with radiologist PRN  Consider information for parents PRN How Do We Respond?

27. Talking to parents 1.Discuss risk vs. benefit 2.Use websites for more detailed explanations 3.Compare to other every day risks

28. compared to background (3.5 mSv/yr) Typical radiation doses compared to background (3.5 mSv/yr) Procedure Effective dose Comparable background dose* Chest x-ray0.02mSv1 month VCUG0.3mSv3 months Dental X-rays0.9 mSv6 months Lumbar spine1.3 mSv7 months CT head2mSv8 months Upper GI3mSv1 year Barium enema7mSv2.3 years CT abdomen10mSv3 years 1 Airline flight0.3mSv2-3 months *Average background dose is 3.5 mSv/year

29. Risk of death from various activities ActivityRisk of death per million/year Having a chest X-ray 1 Visiting Denver for 2 months 1 Traveling 5,000 by air 5 Fishing (drowning) 10 Traveling 1,500 miles by car 40 Motorcycling for 1,000 200 Smoking 1 pack/day 3,500 Being > 55 years age10,000

30. What is CMH doing to lower doses? Pediatric radiologist is actively involved Using US and MRI when possible –Appendicitis and screening Pulsed fluoroscopy –UGI/VCUG – Up to 10X less dose

31. What is CMH doing to lower doses? Pediatric radiologist is actively involved Child size all CT doses –New protocols: 5x less dose Av CT dose: 2009 –CMH: 1025 mSv –Other providers: 1818 mSv 44% less radiation!!

32. What is CMH doing to lower doses? We make sure your patient gets the: Right test (best test with least radiation) –? US or MRI Right time –? Does something else need to be done first? Right way (individualize protocols) –? Contrast or not –Lowest radiation dose possible 44% less for CT on average

33. Thanks for your attention Questions?